Old Sailor 2007

November 14, 2016

The recent discussion between
me and the caretakers of my spouse are a difficult case and is
leading to speculation and misinformation about the nature of
psychogenic illness. I therefore thought it would be useful to
discuss the concept of a conversion disorder in general.According to one of the
doctors who tried to explain me about dealing with the disbelief of
most of the patients they react many times like this: “So you’re
telling me it’s all in my head?”

The concept of what are now
called conversion symptoms is a tricky one for various reasons. There
is an unfortunate stigma attached to the notion that our brains can
cause physical symptoms. Making the diagnosis is complex. Outcomes
are variable and are hampered by the difficulty in communicating the
diagnosis to patients. Conversion disorder symptoms often mask
underlying physiological disease. And the risks of both false
positives and false negatives are high.

This complexity leads some to
argue, in essence, that a conversion disorder symptoms do not exist
at all. The diagnosis is tricky as the patient might feel it like a
way to blame the patient for the failings of the physician. What
are conversion disorder symptoms?

Various terms have been used
over the years to refer to symptoms that are generated by
psychological stress or other factors. Hysteria is an unfortunate
term which was invented to refer to the uterus, as if such symptom
were uniquely female. For obvious reasons the term “hysteria” is
no longer used.

Psychosomatic is still a proper term, meaning
physical symptoms with a mental cause, but the term does have a bit
of a stigma attached. The term conversion disorder is most widely
used today, or psychogenic simply meaning having a mental cause.

As my wife has been diagnosed
with complex PTSD with anxiety related problems and has a psychogenic
overlay. In this case there is an underlying physiological disease or
disorder which then results in stress and anxiety which further
generates the conversion disorder symptoms on top of the
physiological symptoms.

Psychogenic signs and
symptoms are real the patient really experiences them. A conversion
disorder is a real disorder, it is just that the problem is with the
brain’s software, not hardware.

Sometimes my wife is
overtaken by her anxiety disorder, which may be reactive or may be
primary and due to a biochemical disorder in the brain. Anxiety puts
a lot of stress on the body and can absolutely manifest with
physical, and sometimes very dramatic, symptoms. Stress itself can
also manifest with physical symptoms. My wife is living like she is
constantly being scared with very hectic moves

So we all have psychogenic
symptoms at some point in our lives, and we take them for granted.
The fact that more dramatic symptoms can also result from purely
psychogenic causes should not be that surprising.How
do we known when symptoms are psychogenic?

At times patients will have
psychogenic weakness, either partial or complete paralysis of a limb.
This happens to my wife when the tension gets to high at that moment
she loses power in her right hand and she is dragging one leg around.
The first times I was very worried and thought she was having a
stroke as she didn't feel her face on one side as well.True
neurological weakness has certain features which cannot be simulated
(voluntarily or involuntarily) and there are techniques they use in
the neurological exam to look for these features. And strange enough
there was nothing found.

Further still, without a
detailed knowledge of neuroanatomy, patients with psychogenic
symptoms will tend to display distributions of symptoms that do not
follow anatomical pathways. Or they will display patterns of
movements that do not correspond to any part of the motor system.

To summarize, there are cases
in which patients exhibit neurological symptoms which seem to defy
neuroanatomy, reveal features of effort, do not correspond to known
systems in the nervous system, and lack any hard or objective finding
that should be present. Even in these cases, they're likely to do a
full workup looking for an underlying problem (as stated above,
psychogenic symptoms may simply be overlaying a physiological lesion
or disease). In psychogenic cases thorough neuroanatomical scans are
normal, as are physiological tests for nervous system function.

It is not a negative judgment
about the patient, it is simply an attempt to make an accurate
diagnosis.

Sometimes patients are simply
uncomfortable with this situation (perhaps because it was not
communicated to them well). They may seek a diagnosis until they find
someone willing to make one, and then they will blame their previous
doctors for “missing” the real diagnosis. Sometimes the actual
diagnosis is missed, and patients were right to seek other opinions.
But at other times the new diagnosis is the fake, but it is more
acceptable to the patient than the stigma of stress or anxiety
induced symptoms.

It should also be pointed out
that sometimes there is an underlying disorder causing psychogenic
symptoms – serious anxiety or depression. These are just as much
“real” disorders as anything else.

Patients who have disturbing
symptoms due to psychological stress or anxiety will often seek
multiple opinions. In some cases the patient has
what can only be called mental illness, and needs to be redirected
toward psychiatric treatment.

Conclusion

In a perfect world the
unfortunate stigma attached to the psychogenic and conversion
disorder diagnosis would disappear. It is very counterproductive. We
need broader understanding that the brain is also an organ and can
manifest symptoms in a variety of ways. Psychogenic causes are just
another item on the differential diagnosis.